Look at care seeking in the raw data by:
Estimate proportion seeking care at hospital or clinic overall, following methods from Wiens et al PLOS Med
Compare with results if we were to run a RE meta-analysis using default settings in metafor/meta package
Examine differences by age in studies with age stratifications
Examine factors associated with care seeking at a hospital or clinical
Look at care seeking in the raw data by variables that came out as key in main analysis:
Note: Unless otherwise noted, the data presented below represents 161 studies (381 stratified observation entries) in the primary, non-overlapping dataset that asked study participants whether or not the DID seek care for a past diarrheal illness.
We also have information on whether individuals would seek care for a hypothetical diarrheal illness from 27 studies (96 stratified observation entries).
Number of stratified observation entries in the primary dataset at each administrative level by country. Countries with >10 observations displayed as 10.
| variable | observations |
|---|---|
| admin0 | 27 |
| admin1 | 80 |
| admin2 | 157 |
| admin3 | 117 |
| region | observations |
|---|---|
| Middle Africa | 8 |
| Middle East & North Africa | 8 |
| Southern Africa | 9 |
| Europe & Central Asia | 10 |
| North America | 12 |
| Western Africa | 36 |
| East Asia & Pacific | 42 |
| Latin America & Caribbean | 72 |
| South Asia | 84 |
| Eastern Africa | 100 |
Number of stratified observation entries in the primary dataset within different time periods. Year represents the year sampling was completed. Excludes 6 entries missing study dates.
| variable | observations |
|---|---|
| 2000~2004 | 30 |
| 2005~2009 | 113 |
| 2010~2014 | 157 |
| 2015~2022 | 74 |
| NA | 7 |
| variable | value | Total | Percent |
|---|---|---|---|
| Study type | Survey | 304 | 79.8 |
| Intervention | 50 | 13.1 | |
| Surveillance | 23 | 6.0 | |
| Case control | 4 | 1.0 | |
| Sampling method | Cluster | 142 | 37.3 |
| Simple random | 101 | 26.5 | |
| All cases or households | 53 | 13.9 | |
| Stratified | 37 | 9.7 | |
| Systematic | 37 | 9.7 | |
| Other (describe in notes) | 11 | 2.9 | |
| Study population | Caregiver | 212 | 55.6 |
| Head of household | 67 | 17.6 | |
| Resident | 51 | 13.4 | |
| Resident with telephone/email access | 21 | 5.5 | |
| Caregiver of patient at health facility | 11 | 2.9 | |
| Patient at health facility | 6 | 1.6 | |
| Relative/Caregiver (of adult) | 6 | 1.6 | |
| Child with malnutrition | 2 | 0.5 | |
| Other | 2 | 0.5 | |
| Orphan | 1 | 0.3 | |
| Street dweller | 1 | 0.3 | |
| University student | 1 | 0.3 | |
| Outbreak described | No | 308 | 80.8 |
| Yes | 73 | 19.2 | |
| Location desc | Rural | 180 | 47.2 |
| Urban | 99 | 26.0 | |
| Urban and Rural | 73 | 19.2 | |
| Peri-Urban | 24 | 6.3 | |
| IDP or Refugee Camp | 4 | 1.0 | |
| Urban and Peri-Urban | 1 | 0.3 | |
| Income group | Lower middle income | 208 | 54.6 |
| Upper middle income | 73 | 19.2 | |
| Low income | 69 | 18.1 | |
| High income | 31 | 8.1 | |
| Case definition | Diarrhea | 264 | 69.3 |
| Severe diarrhea or cholera | 75 | 19.7 | |
| Gastroenteritis or non-Vc etiologies | 42 | 11.0 |
Note: “Other” regarding self or child almost always refers to all household members, or is a combination of self and child that we could not disaggregate.
| variable | value | Total | Percent |
|---|---|---|---|
| Time care | Any care | 320 | 84.0 |
| First source | 50 | 13.1 | |
| Prior to current visit | 9 | 2.4 | |
| Within 24 h | 2 | 0.5 | |
| Self or child | Child | 253 | 66.4 |
| Other | 105 | 27.6 | |
| Self | 23 | 6.0 | |
| Recall time | 14-15 days | 172 | 45.1 |
| 27-30 days | 90 | 23.6 | |
| 170-365 days | 55 | 14.4 | |
| Not reported | 43 | 11.3 | |
| 2-7 days | 13 | 3.4 | |
| 42-90 days | 8 | 2.1 | |
| Mult choice | No | 337 | 88.5 |
| Yes | 44 | 11.5 |
Note: This excludes individuals seeking care exclusively or explicitly at private hospitals/clinics, i.e., this includes location categories “Hospital/Clinic” (general) and “Public Hospital/Clinic” (more specific).
For multiple choice questions where there is more than one category of hospital/clinic, we take the largest proportion that sought care across them. This is not entirely accurate but the best we can do here. May want to return to this.
Our goal is to estimate the proportion of individuals that seek care when they or their child have diarrhea symptoms in LMICs. Since diarrhea symptoms vary, and some of the categories above had very few observations (e.g., cholera and “other”) we have grouped these into three broad categories of case definitions (below). We’ll start by testing these along with other potential covariates in univariate analyses.
We’ll build generalized linear models with a study-level random intercept following the approach of Wiens et al (2023) PLOS Medicine:
Unadjusted
Univariate models adjusted individually for:
Multivatiate model(s) adjusted for factors identified as significant but not confounding/collinear in univariate models.
NB: Here our observations represent data aggregated to study_id, country, and potential covariate stratifications, for a total of 146 unique observations corresponding to 114 studies. For studies with multiple choice questions, we take the maximum sample size and number seeking care for studies where there were multiple categories of “hospital/clinic” as possible answers.
For the primary analysis, we chose priors that matched the distribution of the data. Specifically, we used a Normal(-0.6,1.5) prior on alpha, where the mean of the distribution (-0.67) matches the median of the observation data (0.339) in logit space. The resulting prior predictive distribution has a median of 0.34 and a mean of 0.37.
In sensitivity analyses, we shift the mean of the prior distribution on alpha up or right 20% in probability space (i.e., mean of -0.38 for the normal distribution in logit space, median of 0.41 for the observation data) and down or left 20% (i.e., mean of -0.99 for the normal distribution in logit space, median of 0.27 for the observation data).
| Version | Proportion (%) |
|---|---|
| Unadjusted | 39.7 (9.5 - 77.4) |
| Unadjusted - shift prior left | 37.1 (8 - 74.5) |
| Unadjusted - shift prior right | 42.6 (11.1 - 80) |
## Number of studies: k = 146
## Number of observations: o = 136822
## Number of events: e = 42388
##
## proportion 95%-CI
## Random effects model 0.3455 [0.2941; 0.4007]
##
## Quantifying heterogeneity:
## tau^2 = 2.0548; tau = 1.4335; I^2 = 99.3% [99.2%; 99.3%]; H = 11.56 [11.26; 11.88]
##
## Test of heterogeneity:
## Q d.f. p-value
## Wald 19392.96 145 0
## LRT 32811.27 145 0
##
## Details on meta-analytical method:
## - Random intercept logistic regression model
## - Maximum-likelihood estimator for tau^2
## - Logit transformation
## - Continuity correction of 0.5 in studies with zero cell frequencies
## (only used to calculate individual study results)
Odds of seeking care for diarrhea for adults vs. children, not adjusting for any other variables. We have 130 observations total here.
| Variable | Category | Odds ratio | |
|---|---|---|---|
| prop_five | 0 | 1 [Reference] | |
| 1 | 1.07 (0.51 - 2.07) |
## Number of studies: k = 119
## Number of observations: o = 112825
## Number of events: e = 32724
##
## proportion 95%-CI
## Random effects model 0.3432 [0.2877; 0.4034]
##
## Quantifying heterogeneity:
## tau^2 = 1.9896; tau = 1.4105; I^2 = 99.2% [99.1%; 99.2%]; H = 11.04 [10.71; 11.39]
##
## Test of heterogeneity:
## Q d.f. p-value
## Wald 14391.78 118 0
## LRT 23792.53 118 0
##
## Results for subgroups (random effects model):
## k proportion 95%-CI tau^2 tau Q I^2
## prop_five = 1 99 0.3436 [0.2842; 0.4084] 1.9190 1.3853 12552.51 99.2%
## prop_five = 0 20 0.3401 [0.2047; 0.5078] 2.3604 1.5363 1693.16 98.9%
##
## Test for subgroup differences (random effects model):
## Q d.f. p-value
## Between groups 0.00 1 0.9671
##
## Details on meta-analytical method:
## - Random intercept logistic regression model
## - Maximum-likelihood estimator for tau^2
## - Logit transformation
Odds of seeking care for diarrhea for adults vs. children, not adjusting for any other variables. We have data from 7 studies that report healthcare seeking at a hospital/clinic by age groups under/over five for LMICs.
| Variable | Category | Odds ratio | |
|---|---|---|---|
| prop_five | 0 | 1 [Reference] | |
| 1 | 1.75 (0.29 - 6.04) |
## Number of studies: k = 14
## Number of observations: o = 26954
## Number of events: e = 7955
##
## proportion 95%-CI
## Random effects model 0.3165 [0.1729; 0.5062]
##
## Quantifying heterogeneity:
## tau^2 = 2.0926; tau = 1.4466; I^2 = 99.2% [99.0%; 99.3%]; H = 10.96 [9.99; 12.02]
##
## Test of heterogeneity:
## Q d.f. p-value
## Wald 1561.41 13 0
## LRT 1775.73 13 0
##
## Results for subgroups (random effects model):
## k proportion 95%-CI tau^2 tau Q I^2
## prop_five = 0 7 0.2844 [0.1079; 0.5665] 2.4459 1.5639 1233.24 99.5%
## prop_five = 1 7 0.3461 [0.1583; 0.5984] 1.6565 1.2870 255.83 97.7%
##
## Test for subgroup differences (random effects model):
## Q d.f. p-value
## Between groups 0.13 1 0.7218
##
## Details on meta-analytical method:
## - Random intercept logistic regression model
## - Maximum-likelihood estimator for tau^2
## - Logit transformation
Odds of seeking care for diarrhea for each indicated variable, not adjusting for any other variables.
| Variable | Category | Odds ratio | |
|---|---|---|---|
| case_cat | Diarrhea | 1 [Reference] | |
| Gastroenteritis or non-Vc etiologies | 2.46 (0.77 - 6.1) | ||
| Severe diarrhea or cholera | 3.21 (1.43 - 6.3) | ** | |
| location_desc | Non-urban | 1 [Reference] | |
| Urban | 1.13 (0.64 - 1.8) | ||
| Urban and non-urban | 1.53 (0.7 - 2.82) | ||
| mult_choice | 0 | 1 [Reference] | |
| 1 | 1.1 (0.54 - 1.96) | ||
| outbreak_desc | 0 | 1 [Reference] | |
| 1 | 3.14 (1.2 - 7.18) | ** | |
| pop_cat | Caregiver | 1 [Reference] | |
| Caregiver of patient at health facility | 8.24 (2.19 - 21.4) | ** | |
| Head of household | 1.05 (0.54 - 1.9) | ||
| Other resident | 1.27 (0.66 - 2.16) | ||
| recall_time | over30_orNA | 1 [Reference] | |
| under30 | 0.38 (0.21 - 0.62) | ** | |
| self_or_child | Child | 1 [Reference] | |
| Other | 0.86 (0.47 - 1.43) | ||
| Self | 0.94 (0.26 - 2.53) | ||
| time_care | Any care | 1 [Reference] | |
| First source | 0.92 (0.44 - 1.69) | ||
| Prior to current visit | 1.52 (0.17 - 5.88) |
In analyses below, the dependent variable is listed in the header.
| Variable | Category | Odds ratio | |
|---|---|---|---|
| case_cat | Diarrhea | 1 [Reference] | |
| Gastroenteritis or non-Vc etiologies | 4.55 (0.02 - 32.93) | ||
| Severe diarrhea or cholera | 0.75 (0.01 - 4.29) | ||
| mult_choice | 0 | 1 [Reference] | |
| 1 | 0.38 (0.01 - 1.94) | ||
| outbreak_desc | 0 | 1 [Reference] | |
| 1 | 0.54 (0.01 - 3.09) | ||
| pop_cat | Caregiver | 1 [Reference] | |
| Caregiver of patient at health facility | 1.98 (0.01 - 13.03) | ||
| Head of household | 1.94 (0.02 - 12.01) | ||
| Other resident | 75.38 (9 - 298.64) | ** | |
| recall_time | over30_orNA | 1 [Reference] | |
| under30 | 0.2 (0.03 - 0.73) | ** | |
| time_care | Any care | 1 [Reference] | |
| First source | 0.35 (0.01 - 1.75) | ||
| Prior to current visit | 2.3 (0.01 - 14.42) |
| Variable | Category | Odds ratio | |
|---|---|---|---|
| case_cat | Diarrhea | 1 [Reference] | |
| Gastroenteritis or non-Vc etiologies | 1.99 (0.02 - 12.6) | ||
| Severe diarrhea or cholera | 24.95 (4.01 - 89.69) | ** | |
| mult_choice | 0 | 1 [Reference] | |
| 1 | 1.77 (0.16 - 7.49) | ||
| pop_cat | Caregiver | 1 [Reference] | |
| Caregiver of patient at health facility | 1.43 (0.01 - 8.62) | ||
| Head of household | 5.8 (0.8 - 21.63) | ||
| Other resident | 1.63 (0.15 - 6.46) | ||
| recall_time | over30_orNA | 1 [Reference] | |
| under30 | 0.09 (0.01 - 0.27) | ** | |
| self_or_child | Child | 1 [Reference] | |
| Other | 2.19 (0.34 - 7.68) | ||
| Self | 1.61 (0.02 - 9.59) | ||
| time_care | Any care | 1 [Reference] | |
| First source | 0.49 (0.03 - 1.9) | ||
| Prior to current visit | 2.24 (0.02 - 14.44) |
| Variable | Category | Odds ratio | |
|---|---|---|---|
| mult_choice | 0 | 1 [Reference] | |
| 1 | 1.46 (0.13 - 6.14) | ||
| outbreak_desc | 0 | 1 [Reference] | |
| 1 | 26.42 (3.49 - 97.28) | ** | |
| pop_cat | Caregiver | 1 [Reference] | |
| Caregiver of patient at health facility | 5.34 (0.14 - 28.6) | ||
| Head of household | 4.76 (0.55 - 17.67) | ||
| Other resident | 4.57 (0.56 - 17.1) | ||
| recall_time | over30_orNA | 1 [Reference] | |
| under30 | 0.03 (0.01 - 0.09) | ** | |
| self_or_child | Child | 1 [Reference] | |
| Other | 4.16 (0.72 - 13.85) | ||
| Self | 1.4 (0.01 - 9.09) | ||
| time_care | Any care | 1 [Reference] | |
| First source | 1.12 (0.14 - 3.94) | ||
| Prior to current visit | 9.8 (0.18 - 55.14) |
| Variable | Category | Odds ratio | |
|---|---|---|---|
| mult_choice | 0 | 1 [Reference] | |
| 1 | 0.86 (0.04 - 3.91) | ||
| outbreak_desc | 0 | 1 [Reference] | |
| 1 | 1.17 (0.01 - 7.25) | ||
| pop_cat | Caregiver | 1 [Reference] | |
| Caregiver of patient at health facility | 10.2 (0.28 - 53.83) | ||
| Head of household | 0.61 (0.01 - 3.19) | ||
| Other resident | 19.33 (2.81 - 68.96) | ** | |
| recall_time | over30_orNA | 1 [Reference] | |
| under30 | 0.17 (0.02 - 0.64) | ** | |
| self_or_child | Child | 1 [Reference] | |
| Other | 12.9 (1.78 - 47.31) | ** | |
| Self | 2.16 (0.02 - 14.49) | ||
| time_care | Any care | 1 [Reference] | |
| First source | 0.61 (0.04 - 2.47) | ||
| Prior to current visit | 3.2 (0.02 - 21.03) |
Is there still an effect of being in an outbreak when we subset the data to just case definitions specific to cholera or severe diarrhea (including death)?
| Variable | Category | Odds ratio | |
|---|---|---|---|
| outbreak_desc | 0 | 1 [Reference] | |
| 1 | 1.99 (0.35 - 6.14) |
Is there still an effect of recall period when we subset the data to just case definitions for general diarrhea (not severe or resulting in death)?
| Variable | Category | Odds ratio | |
|---|---|---|---|
| recall_time | over30_orNA | 1 [Reference] | |
| under30 | 0.67 (0.33 - 1.21) |
In the above analyses, found that we cannot separate effects of:
The trends with self_or_child were also not significant or in the direction we expected, and so we’re focusing on methods and case_cat in the multivariate analyses.
We run two analyses below, adjusting for methods and then adjusting for methods and case_cat. We do not adjust for recall period in the case_cat analysis because there was potential collinearity/confounding between those variables.
Odds that an individual with diarrhea seeks care for themselves or their child overall or by alternate case definitions, adjusting for different ways that the care seeking questions were asked (i.e., timing of care itself).
| Variable | Category | Odds ratio | |
|---|---|---|---|
| pop_cat | Caregiver | 1 [Reference] | |
| Caregiver of patient at health facility | 8.38 (2.34 - 22.13) | ** | |
| Head of household | 1.06 (0.52 - 1.91) | ||
| Other resident | 1.31 (0.64 - 2.23) |
| Variable | Category | Odds ratio | |
|---|---|---|---|
| case_cat | Diarrhea | 1 [Reference] | |
| Gastroenteritis or non-Vc etiologies | 2.2 (0.66 - 5.49) | ||
| Severe diarrhea or cholera | 2.94 (1.33 - 5.61) | ** | |
| pop_cat | Caregiver | 1 [Reference] | |
| Caregiver of patient at health facility | 7 (1.85 - 18.82) | ** | |
| Head of household | 0.95 (0.48 - 1.75) | ||
| Other resident | 0.99 (0.51 - 1.77) |
Stratifications correspond to questions that refer to any care seeking.
| Version | Model | Variable | Proportion (%) |
|---|---|---|---|
| Main result | 1 | Unadjusted | 39.7 (9.5 - 77.4) |
| 2 | Diarrhea | 38.6 (8.7 - 77) | |
| 2 | Gastroenteritis or non-Vc etiologies | 69.9 (25.2 - 98.8) | |
| 2 | Severe diarrhea or cholera | 79.1 (38.1 - 99.1) | |
| 3 | Adjusted for methods | 39 (8.7 - 77.1) | |
| Shift prior left | 1 | Unadjusted | 37.1 (8 - 74.5) |
| 2 | Diarrhea | 35.6 (7.2 - 74.3) | |
| 2 | Gastroenteritis or non-Vc etiologies | 67.2 (21.4 - 98.8) | |
| 2 | Severe diarrhea or cholera | 77.4 (33.8 - 99.2) | |
| 3 | Adjusted for methods | 35.7 (7.1 - 74.4) | |
| Shift prior right | 1 | Unadjusted | 42.6 (11.1 - 80) |
| 2 | Diarrhea | 41.2 (9.4 - 79.9) | |
| 2 | Gastroenteritis or non-Vc etiologies | 71.6 (26.7 - 98.7) | |
| 2 | Severe diarrhea or cholera | 80.6 (39.4 - 99.2) | |
| 3 | Adjusted for methods | 42.2 (10 - 80.3) |
The “estimated” results are the study-level props from the model that includes time_care and case_cat.
## I2: 99.98747, 99.98791, 99.98834, ; tau2: 0.76853, 0.79656, 0.82605,
Sensitivity analyses (Skye found no differences):
Additional country- or study-level covariates to explore (Marissa working on):
Supplementary analyses (potential, in rough order of importance):